Is Outpatient Management of Mandibular Fractures Associated with Inflammatory Complications? An ACS NSQIP Study

Abstract

PurposeThe timing of mandibular fracture repair has long been debated. Prior studies have suggested that expedited treatment with inpatient admission and repair may improve surgical outcomes, though at an increased cost of care. The purpose of this study was to compare the rates of postoperative inflammatory complications (POICs) in patients with isolated mandibular fractures treated non-urgently using an outpatient protocol versus an urgent inpatient protocol. MethodsThe investigators utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to enroll a national-level, multi-institutional sample of patients with isolated mandibular fractures who underwent open repair between 2011 and 2018. The primary predictor variable was treatment protocol: outpatient (elective) and inpatient (urgent/non-elective). The primary outcome variable was POIC (present/absent) within 30 days. POICs included wound infection, wound dehiscence, sepsis, or septic shock, reoperation, readmission, or death. Other reported complications were deemed non-POICs. Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between treatment protocol and POICs. ResultsThe study sample was composed of 1848 subjects with 1134 in the outpatient group and 714 in the inpatient group. The frequency of POICs were 6.53% and 8.96% for the outpatient and inpatient groups, respectively, with no significant difference between groups (P = .052). However, subjects treated as inpatients were 1.51 times more likely to experience any complication (P = .008) due to an increase in non-POICs (P = .028), in particular urinary tract infections (P = .035). After adjusting for variables associated with POICs in bivariate analysis, including age, hypertension requiring medical treatment, and smoking, classification as ASA II (P = .046, OR = 2.21, 95% CI 1.01-4.83), classification as ASA III (P = .020, OR = 2.88, 95% CI 1.18 -7.02), diabetes (P = .004, OR = 3.11, 95% CI 1.43-6.74), and preoperative hematocrit (P = .010, OR = .950, 95% CI 0.913-0.988) were independent predictors of POICs in the regression model. Length of stay was 0.83±2.61 days compared to 2.36±3.63 days for the outpatient and inpatient groups, respectively (P ≤ .001). ConclusionThere was no significant difference in POICs between patients treated as outpatients versus inpatients, though outpatients had fewer non-POICs and a 1.53-day shorter duration of hospital stay. Greater ASA status, diabetes, and lower preoperative hematocrit were independent risk factors for POICs. These data could be useful for institutions seeking to reduce the cost of mandibular fracture repair without compromising the rate of short-term POICs. It may also be relevant for surgeons practicing outside tertiary care centers where an outpatient treatment protocol could make management of mandibular fractures more feasible.